En Route Care and Training for Immediate Responders Explored in November JOT Supplement Covering 2015 MHSRS Proceedings

Supplement 1 of the Journal of Trauma, Volume 81, No.5, carries multiple papers emanating from the 2015 Military Health System Research Symposium. Below are synopses of several. To read the entire supplement, click here.

Machine learning and new vital signs monitoring in civilian en route care: A systematic review of the literature and future implications for the military  

Researchers Nehmiah Liu and Jose Salinas, PhD, reviewed the existing literature related to machine learning (ML) algorithms (MLA) and new vital signs monitoring (NVSM) in civilian en route care in order to determine their potential to fill combat medicine capability gaps. Recent machine learning technologies include those that monitor novel vital signs such as heart rate variability (HRV) and heart rate complexity (HRC). In addition, the photopletysmograph wave form and data quality indices offer potential ways to evaluate the need for lifesaving interventions during en route care.

There continues to be limited means of monitoring and recording data in-flight–such as vital signs, waveforms or interventions made by in-flight personnel—and an imperative to leverage such data to improve care and reduce mortality. Thus, the researchers are optimistic that new innovations could be of benefit in combat scenarios, but caution that further validation is warranted before widespread use. “Almost all studies required further validation in prospective and/or randomized controlled trials,” they determined.

 

Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes

A 2009 change in military combat medicine policy led to the integration of Air Force Pararescuemen with paramedic training into MEDEVAC missions in a bid to decrease mortality. Paramedic level training was thus incorporated into the initial flight medic training of DUSTOFF medics in 2012, and a new program course at Fort Sam Houston provided additional paramedic and critical care training to promote all skill competencies at the EMT–intermediate/paramedic level as well as CCFP certification.

Vikhyat Bebarta, MD, and other researchers at Fort Sam Houston sought to analyze the resulting reallocation of resources in order to determine whether the intended benefit had been attained. In this study, the researchers identified and described medical providers and their specific roles on MEDEVAC missions, and identified associations between provider type, procedures performed, medications administered, survival, and 30-day outcomes.

In a review of more than 1,200 records of US casualties between 2011 and 2014, they determined that 76% of MEDEVAC personnel were medics, 21% paramedics, and 4% were advanced-level providers (ADVs) including nurses, physicians, and physician assistants. Providers with higher-level training were more likely to perform more advanced procedures during en route care; however, there was no significant association between provider type and in-theater or 30-day mortality rates. “More evidence is needed to determine the appropriate level of MEDEVAC personnel training and skill maintenance necessary to minimize combat mortality,” the researchers concluded.

Liu and Salinas argue for research that advances these technologies for en route care. “Importantly, these innovations could not only enhance trauma casualty care for our nation’s war fighters in a complex global environment but also close gaps–specifically, monitoring and the early detection and treatment of various injuries,” say the researchers.

 

Improving national preparedness for mass casualty events: A seamless system of evidence-based care

Researchers Alexander Eastman, MD, William Fabbri, MD, Kathryn Brinsfield, MD, and Lenworth Jacobs, MD, argue in a special report that the U.S. lacks “a unified, coordinated national system to respond to intentional mass casualty attacks….”

The researchers note that our national preparedness goal is thwarted by segmented, compartmentalized, or simply unobtainable investigative, clinical, and medical examiner data following mass casualty events. The distributed nature of the ownership of various segments of the civilian health care system is to blame, they say, and the consequence is that “conjecture, bias, and anecdote inform the civilian section of our national response rather than scientific evidence.”

The Hartford Consensus, they contend, is one attempt to evaluate evidence-based approaches to the problem. The authors review recommendations from successive Hartford Consensus meetings and conclude that immediate responders to mass casualty events, employing bleeding control techniques, hold the key to national resilience. Immediate responders, as defined, include law enforcement officers, bystanders, and even victims.

“Our military colleagues have demonstrated that a robust data collection system, organized scientific study of the problem, and system-wide implementation of evidence-based solutions can significantly improve survival from intentional traumatic injury,” Eastman et al. conclude. “Our duty now is to build the foundations of an analogous civilian system in order to begin to answer the remaining questions and to truly improve our national preparedness.”

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